2025 ICD-10-CM code S04.0

Injury of the optic nerve and its pathways.

Use secondary codes from Chapter 20 (External causes of morbidity) to specify the cause of the injury. Additional codes should be used to identify any associated intracranial injury (S06.-), open wound of the head (S01.-), skull fracture (S02.-), retained foreign body (Z18.-), visual field defect (H53.4-), or blindness (H54.-).

Medical necessity for services related to S04.0 is established by the documented visual impairment resulting from injury to the optic nerve and pathways. This includes diagnostic testing, treatment with corticosteroids or surgery, and follow-up care to monitor vision recovery or manage complications.

Providers diagnose this condition based on patient history (including the cause of the injury), symptoms, eye exams (checking vision and eye pressure), and imaging studies like CT and MRI scans. Treatment can involve corticosteroids or surgery to relieve pressure on the optic nerve.

In simple words: Injury to the optic nerve, which connects your eyes to your brain, due to some form of trauma. This can cause problems with your vision like blurring, loss of sight, blind spots, trouble seeing colors, and eye pain.

Trauma to the optic nerve and its pathways, which transmit visual information from the retina to the brain. This can manifest as blurred vision, vision loss, blind spots, distorted vision, difficulty distinguishing colors, color blindness, or eye movement pain.

Example 1: A patient sustains a head injury in a motor vehicle accident and presents with blurred vision and a visual field defect. Imaging reveals damage to the optic nerve, and the diagnosis is confirmed as S04.0., A baseball player is struck in the eye by a ball, resulting in immediate vision loss. Examination and imaging reveal a severed optic nerve, coded as S04.0., During a surgical procedure near the eye, accidental damage to the optic nerve occurs. The patient experiences vision changes post-operatively, and the complication is coded as S04.0.

Documentation should include the mechanism of injury, detailed clinical findings related to vision changes (visual acuity, visual fields, color vision), imaging reports (CT, MRI), and treatment plan.

** This code excludes birth trauma (P10-P15) and obstetric trauma (O70-O71).

  • Specialties:Ophthalmology, Neurosurgery, Emergency Medicine
  • Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Outpatient Hospital, Ambulatory Surgical Center
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